From the Guidelines
Respiratory infections post kidney transplant pose a significant risk, particularly for Pneumocystis jirovecii pneumonia (PCP), and therefore, prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) is crucial. The risk of respiratory infection is heightened due to the immunosuppressed state of kidney transplant recipients. According to the KDIGO clinical practice guideline for the care of kidney transplant recipients 1, all kidney transplant recipients (KTRs) should receive PCP prophylaxis with daily trimethoprim-sulfamethoxazole for 3–6 months after transplantation.
Key considerations for managing respiratory infections in kidney transplant recipients include:
- Initiating empiric therapy with broad-spectrum antibiotics such as piperacillin-tazobactam or meropenem, along with azithromycin to cover atypical pathogens
- Continuing or initiating TMP-SMX prophylaxis to prevent PCP
- Obtaining respiratory samples for culture and sensitivity testing before starting antibiotics when possible
- Temporarily adjusting immunosuppressive medications, particularly reducing mycophenolate dosage while maintaining calcineurin inhibitors and steroids
- Considering viral infections like cytomegalovirus (CMV) and fungal infections, which may require specific antiviral or antifungal therapy
The emergence of nosocomial PCP clusters among kidney transplant recipients, as reported in studies from 2013 1, highlights the importance of prompt action, instituting universal prophylaxis, reducing patient-to-patient transmission, and examining P. jirovecii genotypes in response to outbreaks. Given the potential for severe disease, hospitalization should be considered for close monitoring and intravenous therapy. Close monitoring of kidney function and careful management of drug interactions with immunosuppressants are also essential.
From the Research
Risks of Respiratory Infection Post Kidney Transplant
The risk of respiratory infection post kidney transplant is a significant concern, with various studies highlighting the potential complications that can arise. Some of the key points to consider include:
- The risk for respiratory complications after solid-organ transplantation, including kidney transplantation, continues to be high 2
- Postoperative respiratory complications are more frequent after liver, heart, and lung transplant recipients, but the incidence is lower in kidney transplant recipients 2
- Lung infiltrates due to multidrug-resistant bacterial infections are increasing and may cause respiratory failure associated with high morbidity and mortality 2
- Infections are a major cause of morbidity and mortality in kidney transplant recipients, and careful pretransplant screening, immunization, and post-transplant prophylactic antimicrobials may all reduce the risk for post-transplant infection 3
- Severe respiratory syncytial virus pneumonia can occur in kidney transplant recipients, even with desensitization therapy 4
- Opportunistic infections, such as BK polyomavirus, cytomegalovirus, Epstein-Barr virus, and norovirus, can present in the first 12 months post-transplant and can be modulated by prior exposures and use of prophylaxis 5
- Pneumocystis pneumonia can occur in kidney transplant recipients, and adjunctive therapy with intravenous immunoglobulin may be effective in severe cases 6
Types of Respiratory Infections
Some of the specific types of respiratory infections that can occur in kidney transplant recipients include:
- Multidrug-resistant bacterial infections 2
- Respiratory syncytial virus pneumonia 4
- Pneumocystis pneumonia 6
- Opportunistic infections, such as BK polyomavirus, cytomegalovirus, Epstein-Barr virus, and norovirus 5
Treatment and Prevention
Treatment and prevention strategies for respiratory infections in kidney transplant recipients may include:
- Early, broad-spectrum empiric antibiotic therapy 2
- Lung protective mechanical ventilation 2
- Appropriate timing of tracheotomy for patients who need prolonged mechanical ventilation 2
- Prophylactic antimicrobials 3
- Immunization 3
- Adjunctive therapy with intravenous immunoglobulin in severe cases of Pneumocystis pneumonia 6